Tuesday, 27 July 2010

Vanessa was a woman in her late 20’s, who lived on an estate in Charwood with her two sons, aged 6 and 8. Vanessa had bipolar affective disorder. About 20 years ago, over a two year period, I had to assess her under the Mental Health Act on 8 separate occasions, invariably during a hypomanic episode.

Most of the time I liked Vanessa. Most of the time she liked me. I felt I knew her. And that was my mistake.

Her default state was to be vivacious and amusing. When she was high, her vivaciousness increased exponentially. She could be deliberately (and also unintentionally) funny.

I remember one evening assessing her in her home. She had taken a liking to the GP. A great liking. She started to flirt with him. Ignoring the psychiatrist and me, she concentrated all her powers on attempting to seduce him with her feminine wiles. She did this by the device of lighting a match, fixing her eyes on his, then pretending to blow the match out. Her lips quivered seductively, on the point, the very cusp, of extinguishing the flame. Her breath would cause the flame to tremble and gutter. But then, teasingly, she would desist, allowing it to burn a little longer, narrowing her eyes a little as she gazed into the GP’s own perplexed and startled eyes. She repeated this with increasing levels of salaciousness. And finally, at the moment when the flame was about to reach her fingers, she delivered the coup de grace.

We were all entranced by this display. But it didn’t stop us detaining her.

It also didn’t seem to interfere with my ability to work with her. Usually, when she recovered, she would recognise that, if on occasion I had had to exert my authority under the Mental Health Act, it was done in the interests of herself and her sons, and did not hold it against me. But over time, an edge of irritability and maliciousness crept into her character, especially when she was high.

The last assessment I undertook (at least in that two year period – there was one more, but that will remain for another post) was also the most spectacular. We knew Vanessa was going to become unwell again because she was refusing her medication. It was only a matter of time. One day, her community nurse reported that she was becoming high again. I contacted the Consultant Psychiatrist and the GP, and in the meantime, we went out to see her to see if she might agree to an informal admission.

“Hi there, Vanessa,” I said as she opened the door. “You can probably guess why I’ve been asked to come to see you.”

Her face was sour. “You’d better come in, I suppose,” she said, ungraciously.

It was the middle of summer. Her two boys were at home. She sent them to play upstairs. The three of us sat in her kitchen. She made herself and the nurse a cup of coffee, but pointedly did not ask me. As I asked her questions about how she had been and whether or not she was taking her medication, she just stared at me with increasing animosity. Finally, she looked at the nurse and said to him, “Is he always this much of an arsehole? Shall I throw this coffee over him?”

I tried to reassure her, but she wasn’t having any of it. She left the kitchen and went into her living room. I followed her.

“I’m going out for some fresh air,” she shouted. “I can’t stand the stink in here!” She went out of the patio doors into her back garden. The nurse and I cautiously followed her.

She continued to shout to no-one in particular. “The arsehole’s here to steal my kids!”

The neighbours could certainly hear her. They knew her when she was well, and they knew her when she was unwell. They knew something interesting was going to happen. Down the terrace in either direction, I could see people bringing out their deckchairs or leaning out of upstairs windows in order to get the best vantage point of the spectacle to come.

I didn’t particularly like conducting a Mental Health Act assessment with such a large audience.

Vanessa did not like this suggestion at all. She suddenly launched herself towards me, arms flailing. She proceeded to box my ears, hitting me hard on either side of the head and knocking my glasses into the grass.

I backed off, while the nurse grabbed her from behind and pinned her arms to her sides, giving me a chance to find my glasses.

“Leave our mum alone!” her boys shouted at me from the upstairs window.

Before I knew what was happening, they started firing down a rain of toy arrows, which, although the suckers were not actually painful, were certainly humiliating, especially as the observing neighbours were making appreciative comments.

Vanessa broke free from the nurse and ran back through the house and out of the front door.

I followed her, keeping a safe distance, grateful to get away from the arrows.

“Have you heard a joke?” she shouted at the top of her voice to the entire street. “It’s a fucking funny joke. It goes like this.”

She started to walk down the street, shouting as she went. As she passed each car, she deftly snapped off its radio aerial.

“What’s the difference between a Rottweiler and a Social Worker?” she shouted. “You’ll like this, it’s a fucking funny joke. You get your kids back from a Rottweiler! There, that’s a funny fucking joke isn’t it?”

She continued in this vein until she reached the end of the street and went off through the estate.

A police car came round the corner and stopped. The lone police officer wound down his window as the nurse and I approached.

“We’ve had a complaint,” he said. “A report of shouting.”

I explained to him what was happening, and suggested that she be detained under Sec.136 so that she could be taken to a place of safety to be assessed (with less risk to the assessors).

“I think you’ll need more than one officer to detain her,” I said. “She’s wild.” I explained what had happened to me. He did not seem impressed.

“I’ve got a colleague in another car on the way,” he said. “I’m sure we can handle her.”

As he was talking to us, we heard his colleague over the police radio.

“I’ve located the suspect,” we heard him say. “I’m about to apprehend her.” Then we heard a lot of shouting and screaming. “Assistance requested – aah!” we heard the other officer say.

“You get your fucking kids back from a Rottweiler!” we heard Vanessa shout in the background.

The officer drove off at full speed to assist his colleague.

I went to the police station. By the time I was ushered into the custody office, I knew Vanessa was there. I could hear her shouting at the top of her voice from one of the cells. She was saying something about Social Workers and Rottweilers.

Thursday, 1 July 2010

During my years practising first as a Mental Welfare Officer, then as an Approved Social Worker and now as an AMHP, I’ve been in a few tight spots (being chased round a bungalow by an old man with dementia brandishing a shotgun being one that springs to mind). However, I have only rarely been actually physically assaulted. I like to think that’s because I know how to keep myself safe and de-escalate potentially violent situations, but perhaps luck also has something to do with it. When I look at the situations in which I was assaulted, generally I can recognise that I’ve made mistakes of judgment (although sometimes they are completely unpredictable).

I’ve already mentioned Derek in my August 2009 post, The Mental Health Act Assessment of Fear. I would certainly count what happened there as a physical assault. In fact, there’s something uniquely repulsive and invasive about someone spitting into your face. Over the next couple of posts I’ll write about some other memorable incidents.

Violet

Violet was 93 years old. She lived alone, with no other living relatives. She was suffering from dementia. Although she was remarkably physically fit for her age, she was forgetting to eat, was going out at night and forgetting where she lived, and was generally putting herself in danger. She had also become quite paranoid, and although she had initially accepted home care from social services, she had begun to accuse them of stealing things from her house, and had stopped letting them in. Her social worker was becoming increasingly worried about her, as it was only the home carers who were ensuring she was eating adequately.

When her GP, the old age consultant psychiatrist, her social worker and I arrived at her house early in the evening and knocked on her door, at first there was no reply. We could see her peering round the curtains, but she wouldn’t come to the door. However, while we discussed what to do next, her curiosity clearly got the better of her, because she opened the door. Recognising her GP (GP’s often seem to have a supernatural ability to persuade reluctant patients to cooperate with assessments), Violet decided to let us in.

At first, Violet listened politely to us as we asked her questions and tried to reason with her. She made an effort to answer us, but her answers made little sense. She wanted to defer a decision until her husband came home from work (he had died 20 years previously); she didn’t need home care because her daughter did all her shopping for her (she had never had children); she never went out after dark (the police had had to bring her home in the early hours on several occasions). It was clear that her dementia was quite advanced.

Once we had completed the interview, we withdrew into her kitchen to discuss our conclusions, and then completed the forms for detention under Sec.2. Then it was my job to tell her what was going to happen next.

Violet again appeared to listen politely to me. However, when she realised that our intention was to admit her to hospital, she became quite irate, insisting that she was as fit as a fiddle and that there was nothing at all wrong with her. The doctors made their excuses and left, leaving her social worker and me to manage her while waiting for the ambulance.

I continued to try to negotiate with her and prepare her for the arrival of the ambulance. She ran to the top of the stairs, then rather impressively high stepped down the flight of stairs, saying, “Look, look! There’s nothing wrong with me, is there young man?”

She then ran straight upstairs again and went into a bedroom. I followed, rather more slowly. When I went into the room, she was standing behind the door and was holding a full roll of wallpaper in her hand. While I tried to work out what was happening, without warning she swung the roll at me like a baseball bat, and hit me with surprising force on the side of the head.

For a moment, I reeled sideways and nearly fell over, completely disoriented. Full rolls of wallpaper pack quite a punch, and although I was not significantly injured, I was certainly in pain.

I staggered down the stairs just as the ambulance crew arrived.

“So we’ve got a 93 year old lady, have we?” the ambulance man asked, looking at his paperwork.

“Yes,” I replied, rubbing the side of my head, which now had a noticeable contusion. “But you need to be careful, she’s quite aggressive. She’s just hit me.”

The ambulance man looked at Violet, who was again high stepping on the stairs, and then looked rather pityingly at me.

“I don’t think we’ll have too much trouble managing her,” he said slightly condescendingly, and proceeded towards her up the stairs.

“Hello, Violet,” he said, smiling insincerely as he approached her, holding his hands out. “We’ve come to take you to hospital.”

“Oh no, you’re not,” she said, and punched him on the nose.

The ambulance man fell backwards, bumping down the stairs and clutching his nose, which was bleeding. His colleague rushed up the stairs, getting past her, and then grabbed her from behind, clutching her round the waist and pinning her arms against her sides.

“Quick, grab her legs!” he shouted at me.

I was a bit taken aback. I don’t normally make any physical contact with patients in my role as an AMHP (or as a social worker, come to that), but instinctively did as I was told, gripping her ankles, and between the two of us we managed to carry her downstairs, despite her objections and struggles. The ambulance men then strapped her into a chair and wheeled her into the ambulance.

“And let that be a lesson to you, you ruffian,” I heard Violet say triumphantly to the injured ambulance man as they closed the doors.

Moral: Never underestimate the capacity of a 93 year old lady to inflict significant harm.

Subscribe!

Join!

Why not join? With over 3500 members, it's an ever growing, but nevertheless friendly and supportive group. AMHP's, AMHP trainees, social work and nursing students, service users, carers and relatives, and others with a professional or personal interest in mental health, such as psychiatrists, nurses, psychologists, police officers and bloggers, all get on together (most of the time!). It's a great place to pose a question or discuss thorny issues relating to the Mental Health Act, the Mental Capacity Act and mental health in general.

Follow the Masked AMHP on Twitter!

The Masked AMHP can now be followed on Twitter: @MaskedAMHP You know you want to.

Explanation of Terms used in this Blog

About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.